Factors associated with adverse sexual outcomes among
college students.

Abstract:

This study examined factors associated with adverse sexual outcomes
among 24,963, 18-24 year old undergraduate college students
participating in the Spring, 2004 National College Health Assessment
Survey. Alcohol use, mental health problems, and higher rates of
perceived peer sexual activity were associated with increased odds of
sexually transmitted infections (STIs) and unintended pregnancy. In
contrast, living on campus reduced students' odds for STI
acquisition, and high grade point average was associated with reduced
odds for unintended pregnancies. Results suggest that factors associated
with college students' sexual health behaviors are complex and
often interrelated and deserve further and more in-depth study.

Subject:

Mental health
(Health aspects)
College students
(Sexual behavior)
College students
(Surveys)
College students
(Health aspects)
Disease transmission
(Health aspects)

Sexual health problems are one of the most serious health concerns
among the adolescent and young adult population (Eng & Butler,
1997). Young adults, including college and university students,
frequently engage in behaviors that put them at increased risk for
sexually transmitted infections (STIs) and unintended pregnancy.
According to the Centers for Disease Control and Prevention, of the
fifteen million new cases of STIs that occur in the United States every
year, an estimated 9.1 million occur among 15-24 year olds (Weinstock,
Berman, & Cates, 2004). In addition, approximately 900,000 teenagers
become pregnant in the United States every year. The majority of these
pregnancies occurs among 18-19 year olds, and most are unintended
(Klein, 2005).

SEXUAL BEHAVIORS AMONG COLLEGE STUDENTS

Nearly three fourths of undergraduate college students report they
are sexually active, with many college students engaging in increased
levels of sexual activity and sexual experimentation (ACHA, 2006).
Sexually active college students are more likely to be at risk for
contracting STIs and experiencing unintended pregnancy due to patterns
of sexual behavior including having multiple partners and inconsistent
use of condoms (Kirby, 2001; Lewis, Melton, Succop, & Rosenthal,
2000; Scholly, Katz, Gascoigne, & Holk, 2005).

Although most college students are aware that condom use should be
the primary method of STI prevention for sexually active individuals,
fewer than half report using condoms consistently (Scholly et al., 2005;
Zak-Place & Stern, 2004). One key reason may be the importance of
social norms and group connectedness in affecting sexual behavior.
Research indicates that if a group has clear norms against unsafe sexual
practices, then adolescents associated with this group will be less
likely to engage in sexual risk-taking. In contrast, when adolescents
are connected to groups with more permissive values, there is an
increased likelihood that they will engage in risky sexual behavior
(Kirby, 2001). The impact of social norms on sexual health behavior has
been documented in a small number of studies within the college student
population (Lynch, Mowrey, Nesbitt, & O'Neill, 2004; Scholly et
al., 2005; Seal & Agostinelli, 1996).

Another factor impacting college students' sexual risk-taking
is an unrealistic perception of low vulnerability to STIs and unintended
pregnancy. Students are often aware of the dangers of contracting an STI
such as HIV, yet most college students view HIV infection as an
improbable health concern (Sands, Archer, & Puleo, 1998). The gap
between levels of awareness and actual behavioral practices results in
students who demonstrate low rates of STI preventive behavior (Sands et
al., 1998; Zak-Place & Stern, 2004).

Excessive alcohol use is also a factor linked to high-risk sexual
health practices among college students (Turchik, Garske, Probst, &
Irvin, 2009). Alcohol use often diminishes inhibitions and rational
decision-making, thereby increasing the incidence of unprotected sex
(Kirby, 2001). Thousands of students annually experience problems
related to their alcohol use. Common practices such as binge drinking,
drinking rituals and drinking games often contribute to students'
increased risk for unprotected sex, sexual assault and abuse (Maney,
Laurenceau-Medina, Mortensen, Vasey, Moore, & Gates, 2003; Wechsler,
Lee, Kuo, & Lee, 2000). The link between college students'
excessive alcohol use and risky sexual behavior may be the result of a
campus environment that supports such behavior. It is difficult for
students to say "no" to alcohol misuse when the campus culture
encourages activities which result in high risk health behaviors (Maney
et al., 2003; Wechsler, Lee, Nelson & Kuo, 2001).

Mental health problems can also have a profound effect on all
aspects of campus life, negatively impacting students' physical,
emotional, cognitive, and interpersonal functioning (Kitzrow, 2003). The
severity of problems for which students are seeking help at college
counseling centers has increased since the 1980s and includes suicidal
ideation, severe depression, substance abuse, anxiety, and feelings of
distress (Pledge, Lapan, Heppner & Roehlke, 1998). These mental
health issues are also potentially linked to high-risk sexual practices
that put students at greater risk for unintended pregnancies and
contracting STIs (Martens, Page, Mowry, Damann, Taylor, & Cimini,
2006; Sax, 1997).

The purpose of this study is to examine factors that influence the
sexual health practices of undergraduate college students ages 18-24
years old and to identify factors independently associated with becoming
unintentionally pregnant or contracting a sexually transmitted
infection.

METHODS

This study utilizes a secondary data source, the 2004 National
College Health Association's National College Health Assessment
(NCHA) Survey. Eighty U.S. post-secondary institutions from all Carnegie
classifications representing varied geographic regions of the United
States participated. The NCHA survey currently provides the most
comprehensive secondary data set available for investigating the factors
that influence college students' health behavioral practices (ACHA,
2006). Only those institutions that used a random sampling technique to
identify student participants were included in this study's final
data set. This study was reviewed and approved by the University of
Hawaii's Institutional Review Board.

The sample for this study was limited to 18-24 year old full-time
students who reported being sexually active, defined as having had
sexual intercourse in the last school year. Sexually active students
were selected, as they were potentially at risk for an unintended
pregnancy or STI. The 18-24 year old age range was selected, as numerous
studies indicate that this age group has a high incidence of health risk
behaviors, including sexual risk-taking and alcohol misuse (Dekin,
Cabrera, Vogt, & Volkwein 1995; Lewis et. al, 2000; Wechsler et al.,
2000), and the vast majority of unintended pregnancies and STIs occur
among this age group (Cooper, 2002; Kirby, 2001; Klein, 2005). Because
one of the study's research questions was to determine the impact
of campus involvement on sexual risk-taking behavior, it was necessary
to include only full- time students, as they are on campus more often,
which provides greater opportunities to participate in activities
related to academic and social involvement (Astin, 1993). Adopting these
criteria resulted in a final sample size of 24,963.

Two dichotomous dependent variables were selected to reflect
adverse sexual health related outcomes: contracting an STI, or
experiencing an unintended pregnancy in the last school year.

Independent variables included sociodemographic variables: age,
gender, ethnicity (white vs. other), sexual orientation (heterosexual
vs. not heterosexual), year in school, domestic vs. international
student status, relationship status (single, uncommitted vs. in a
committed relationship). Other independent variables included four
school-involvement variables: living on campus (yes or no), being a
member of a fraternity or sorority (yes or no), number of hours working
per week for pay, and grade point average (GPA) with high GPA defined as
greater than or equal to 3.0 on a 4 point scale.

Alcohol use/abuse was assessed through three questions: number of
drinks ingested last time student "partied/socialized," number
of hours student drank alcohol last time student
"partied/socialized," and number of times five or more
alcoholic drinks were ingested at one sitting over the past two weeks.
These items were analyzed individually and also aggregated to form a
composite "alcohol use" variable for logistic regression
analyses. Cronbach's alpha coefficient for the three items = 0.79.

Two questions were used to assess STI risk reduction behaviors: use
of condom at last oral intercourse (yes or no) and use of condom at last
vaginal intercourse (yes or no). Three questions were used to assess
risk reduction behaviors for pregnancy prevention: use of oral
contraceptive to prevent pregnancy (yes or no), condom use to prevent
pregnancy (yes or no), emergency contraception use in the last school
year (yes or no). Three questions were asked to assess sexual activity:
how many times within the past 30 days did you have oral sex, vaginal
sex, anal sex. An additional three questions were asked to assess
perceived peer sexual behaviors: how many times within the past 30 days
do you think the typical student at your school had oral sex, vaginal
sex, anal sex. These latter three items were analyzed individually and
also aggregated into a composite "perceived peer norms"
variable for logistic regression analyses. Cronbach's alpha for
responses to the three perceived peer sexual behavior questions = 0.77.

Student emotional health was assessed through six questions each
pertaining to the last school year: how many times have you felt things
were hopeless, how many times have you felt overwhelmed by all you had
to do, how many times have you felt very sad, how many times have you
felt so depressed that it was difficult to function, how many times have
you seriously considered attempting suicide, and how many times have you
attempted suicide. These items were analyzed individually and also
aggregated into a composite "emotional health" variable for
logistic regression analyses (Cronbach's alpha = 0.84). Student
assault and relationship abuse was assessed by the answers to six
questions each pertaining to the last school year: have you experienced
verbal threats, have you experienced sexual touching against your will,
have you experienced an attempted sexual assault, have you experienced a
sexual assault, have you been in a relationship that was physically
abusive, and have you been in a relationship that was sexually abusive.
These six items were analyzed individually and also aggregated into a
composite "relationship abuse" variable for logistic
regression analyses (Cronbach's alpha = 0.66).

A logistic regression model was developed for each of the two
dichotomous dependent variables (STI or unintended pregnancy in last
year) to assess which independent variable(s) were independently
associated with each of the two outcome variables. Each
sociodemographic, school involvement, composite alcohol use, composite
perceived peer sexual behavior, composite emotional health, and
composite relationship abuse variable was included in the two logistic
regression models. For the STI model, additional variables related to
STI risk reduction behaviors were added. For the unintended pregnancy
model, only students identifying as heterosexual females were included
in the analysis, and pregnancy prevention risk reduction behaviors were
added.

Descriptive statistics and logistic regression analyses were
performed using SPSS version 15.

RESULTS

DESCRIPTIVE STATISTICS

Tables 1-4 provide the descriptive statistics for the study. The
mean age of the study population was 20.35 years, 34% of the study
population was male, and the majority of students in this study
ethnically identified as Caucasian (80%). The race/ethnicity
demographics total more than 100% as categories were not mutually
exclusive. Forty-seven percent of students were "single"
(e.g., in an uncommitted relationship) (Table1).

Forty-six percent of students in the study sample reported living
on campus versus living off campus. Ten percent reported membership in a
fraternity or sorority. Eighty-six percent reported having a high GPA of
at least 3.00 on a 4 point scale (Table 2).

Forty-seven percent of students reported using a condom the last
time they had vaginal intercourse. In terms of pregnancy risk reduction
strategies, 68% used oral contraceptives and 64% used condoms (although
not necessarily consistently). Twelve percent reported using emergency
contraception (morning after pill) in the last school year (Table 3).

During the past school year students reported feelings of
"being overwhelmed" a mean of 4.66 times and being sad 3.41
times. Suicidal feelings and actual suicide attempts were reported less
frequently (Table 4).

In terms of the study's dependent variables, 4.5% of students
reported being diagnosed with one or more STIs, and 2.5% of female
students reported becoming unintentionally pregnant within the past
school year.

LOGISTIC REGRESSION ANALYSIS STI MODEL FINDINGS

Table 5 provides the results of the logistic regression analysis
examining the association between the independent variables and
students' likelihood of being diagnosed with an STI (Table 5).
Older students (within the 18-24 year old age group) were more likely to
have been diagnosed with an STI during the past year [odds ratio (OR) =
1.17, 95% confidence intervals (CI): 1.10-1.26]. Heterosexuals were
significantly less likely to have contracted an STI (OR = 0.64, 95% CI:
0.49-0.83). Males were significantly less likely than females to have
been diagnosed with an STI during the last school year (OR = 0.39, 95%
CI: 0.32-0.47).

Two variables related to student involvement on campus were
significant. Membership in a fraternity or sorority compared with not
being a member of a fraternity or sorority increased the likelihood of
contracting an STI (OR = 1.33, 95% CI: 1.07-1.63). In contrast, living
on campus significantly reduced the likelihood of contracting an STI (OR
= 0.69, 95% CI: 0.58-0.81).

Perception of peers' sexual activity was significantly related
to likelihood of contracting an STI (OR = 1.12, 95% CI: 1.05-1.21). This
can be interpreted as students who perceived their peers to be the most
sexual active were more likely to contract an STI.

Students with higher levels of alcohol use were at greater odds of
contracting an STI (OR = 1.13, 95% CI: 1.04-1.23).

Students' emotional health also had an impact on their odds of
contracting an STI. Students who experienced higher levels of depression
and/ or suicidal ideation than the sample mean had an increased
likelihood for infection (OR = 1.38, 95% CI: 1.23-1.52).

Finally, in terms of sexual practices, students who reported condom
use during last oral intercourse and last vaginal intercourse showed a
decreased likelihood for STI acquisition (OR = 0.55, 95% CI: 0.30-0.98
and OR = 0.85, 95% CI: 0.730.98 respectively).

PREGNANCY MODEL FINDINGS

Table 6 provides the results of the logistic regression analysis to
explain students' likelihood of becoming pregnant (Table 6).
Students who identified as Caucasian were at decreased odds for
unintentional pregnancy during the past school year (OR = 0.51, 95% CI:
0.38-0.67). Other background variables such as year in school (OR =
0.80, 95% CI: 0.68-0.94) and age (OR = 1.18, 95% CI: 1.02-1.34) were
also significant.

Students with higher GPAs (3.0 or above) had approximately 2.6
times lower odds of an unintentional pregnancy (OR = 0.39, 95% CI:
0.29-0.52).

Students who perceived their peers to be the most sexually active
had an increased odds of unintentional pregnancy (OR = 1.27, 95% CI:
1.121.44).

Greater emotional health challenges (i.e., depression and suicidal
ideation) were associated with an increased odds of an unintentional
pregnancy (OR = 1.36, 95% CI: 1.06-1.60). Students who reported using a
condom to prevent pregnancy were at decreased odds of unintentional
pregnancy (OR = 0.46, 95% CI: 0.38-0.68). In contrast, students who
reported that they used emergency contraception during the last school
year were at increased odds for unintentional pregnancy (OR = 2.77, 95%
CI: 2.02-3.71).

DISCUSSION

A unique aspect of this study was its ability to identify a wide
array of variables that were independently associated with college
students' likelihood of contracting an STI or experiencing an
unintended pregnancy. The inclusion of a large nationally distributed
sample and the use of a validated survey instrument are key strengths of
this study.

Increasing age was related to increased odds for contracting an STI
and experiencing an unintended pregnancy. Results from an earlier NCHA
Survey, found that 8 of 10 college students between the ages of 18 and
24 years were sexually active, 25% of students had six or more lifetime
sex partners, and only a small percentage of students used condoms
consistently to prevent pregnancy or STI (Douglas, Collins, Warren,
Kann, Gold, Clayton, Ross, & Kolbe, 1997). College students'
risk for STIs and unintended pregnancies, therefore, likely increases as
they get older due to their increased exposure to multiple sexual
partners without the use of adequate protection (Cooper, 2002; Douglas
et al., 1997).

The finding that women were at increased odds for STIs, is
consistent with national surveillance data for both gonorrhea and
chlamydia among 15-24 year olds (CDC, 2007). Gender differences in STI
rates may reflect more aggressive screening programs targeting women.
Many college women are screened annually for a variety of STIs, however
routine STI testing is much less common among college males.

The finding of increased odds of STIs among nonheterosexuals is
also consistent with national reports (CDC, 2007; Hall, Song, Rhodes,
Prejean, An, Lee, Karon, Brookmeyer, Kaplan, McKenna, & Janssen,
2008). Gay and bisexual men are currently the groups most affected by
HIV infection in the United States (Hall et al., 2008).

Although the current study lends support to the link between
alcohol use and STIs, it did not demonstrate a significant relationship
between alcohol use and unintended pregnancy. This unique finding is in
contrast to previous research, which does demonstrate a link between
alcohol and unintended pregnancy, especially among women who were binge
drinkers (Naimi, Lipscomb, & Gilbert, 2003). One possible
explanation for the discrepancy in findings could be explained by
college students' methods of birth control. Research has shown that
alcohol use is related to inconsistent condom use (Cooper, 2002; Martens
et al. 2006). However, college students often use birth control pills
rather than condoms for pregnancy prevention (Douglas et. al, 1997;
NCHA, 2005) and oral contraception would be potentially less negatively
affected by excessive alcohol use.

Previous research has demonstrated that psychological dysfunction
associated with emotional health problems can result in increased
risk-taking and decreased self-care (McNutt, Carlson, Persuad, &
Postmus, 2002). In addition, students who experienced moderate to severe
depression were at greater risk for academic impairment, which included
interpersonal problems with members of the campus community and
decreased academic productivity (Heiligenstein et al., 1996). The
current study establishes a specific connection between impaired
emotional health and increased STI and unintended pregnancy occurrence
among college students. One possible explanation for this finding is
that emotional health problems impede students' ability to practice
risk reduction strategies, such as consistent condom use and correct and
consistent use of other contraceptive methods such as remembering to
take oral contraceptive pills as prescribed.

The study results did not reveal any consistent relationship
between sexual assault and/or dating violence and increased occurrence
of unintended pregnancy and STI acquisition. One possible explanation
may be related to how the relationship abuse variable was defined in the
study and the general nature of the construct itself. For example,
experiencing verbal threats may not have the same impact on
students' STI and pregnancy risk as if they experienced physical
assault. If this variable was more narrowly defined (e.g., including
only physical violence within a dating relationship), a statistically
significant relationship between assault and the study's outcomes
might have been found.

College students' sexual behavior is often characterized by
inconsistent condom use (Dahl, Gorn, & Weinberg, 1997; Lewis et al.,
2000; Zak-Place & Stern, 2004). However, when used correctly and
consistently condoms are a highly effective method for preventing both
STIs and pregnancy (Cates & Steiner, 2002). The findings from the
current study reinforce the importance of condom use among the college
population. Students who used condoms during last oral and vaginal
intercourse were at decreased odds for STIs and those students who used
condoms as a method of birth control also reduced their odds for
pregnancy.

Over the past decade, emergency contraceptive pills (ECPs) have
become much more readily available at college health centers and ECPs
have been shown to be extremely safe for the vast majority of women who
use it (Miller & Sawyer, 2006). When ECP is taken within 72 hours of
unprotected intercourse, it is estimated to be 75-86% effective in
preventing pregnancy (Miller & Sawyer, 2006). Although the number of
women who used ECP as a method of preventing pregnancy during the last
school year was relatively small, the findings indicated that ECP use
was associated with significantly increased odds of unintended
pregnancy. One possible explanation may be that these students failed to
use ECP within a 72 hour period after unprotected sex. It is also not
known if students took ECP after every incidence of unprotected vaginal
intercourse, which would also increase their risk for unintended
pregnancy. Another possible explanation is that students taking ECP were
relying on ECP as their primary birth control method and were not using
a more effective contraceptive method. A recent study of college
students in Hawaii also demonstrated a positive association between ECP
use and unintended pregnancy (Parrish, Katz, Grove, Maddock, &
Myhre, 2009).

A significant association was demonstrated between students'
perceived normative behaviors and their odds of acquiring an STI and
becoming pregnant. Previous social norms research found that college
students consistently overestimated the sexual health norms on campus
(Cooper, 2002; Lewis & Neighbors, 2006). These misperceptions may
result in increased risk-taking as students try to conform to
inaccurately perceived prevalence of high-risk sexual practices (Martens
et. al., 2006; Scholly et al., 2005). It may also be that students at
greater risk for STIs and unintended pregnancies associate themselves
more closely to peers with perceived high-risk sexual behaviors.

The elevated odds of STIs associated with fraternity or sorority
membership and the reduced odds of STIs and unintended pregnancy
associated with living on campus may be related to differences in rates
of alcohol consumption between the two groups. Greek members comprise a
subgroup on campus that consumes alcohol in greater quantities,
misperceives the risks of alcohol abuse, and emulates a social
environment in which drinking alcohol is a key part of college life
(Barry, 2007). In contrast to the high rates of binge drinking that are
common in fraternities and sororities, over 40% of all college students
under the age of 21 live in on-campus substance-free housing, where the
lowest undergraduate binge drinking rates can be found (Wechsler et al.,
2002).

The inverse relationship between high GPA, year in school and odds
of unintended pregnancy conforms with Astin's findings that
pregnancy was a common reason for women to drop out of college (Astin
1993). Hence high GPA may reflect greater engagement in academics and
greater adherence to effective contraceptive practices allowing women to
avoid an unintended pregnancy, and successfully progress in their
college career.

LIMITATIONS AND CONCLUSIONS

LIMITATIONS

The study's findings should be interpreted in light of some
key limitations. First, the data used in this study were cross-sectional
thus limiting the researchers' ability to draw causal inferences.
The use of a cross-sectional data set to create a main effects model
also limited the researchers' ability to examine the interaction
effects between specific variables within the study. Although
cross-sectional studies can provide useful data, they are not optimal
for illuminating processes by which health-risk behaviors are temporally
associated (Cooper, 2002). As a result, additional research is needed to
examine factors that contribute to STIs and unintended pregnancy among
college students from a more in-depth, and longitudinal, perspective.

Another limitation is the generalizability of the study's
findings. Although the NCHA survey is the largest nationwide
comprehensive sample of college students' health behaviors, the
study population is predominately Caucasian. This may limit the ability
of the study's findings to reflect the behaviors of all students
currently enrolled in higher education institutions. Current research in
higher education has demonstrated a need to expand the vision of the
college experience to reflect the growing diversity of U.S. college
students (Pascaralla & Terenzini, 2005).

Lastly, with such a large sample size and number of comparisons,
there is the possibility that some of the observed findings may reflect
type I error. This would be of particular concern for independent
variables demonstrating significant associations but with odds ratios
close to the null value (e.g., small effect sizes). However, over half
of our observed significant associations were highly significant with
very low p-values (p [less than or equal to] 0.001) making chance an
unlikely explanation.[less than or equal to]

CONCLUSIONS

College health professionals must work to develop effective
education and intervention strategies for the early identification of
students exhibiting high risk health behaviors. Given how strongly
alcohol use is associated with risky sexual behavior, education programs
designed to promote safer sexual practices should also address college
students' alcohol use patterns. Educational efforts might also
include social norms interventions designed to help students adopt less
exaggerated views of their peers' drinking and sexual behavior
norms.

Expanded education efforts and future research to examine the
interrelationship between mental health, sexual health, social and
residential factors, and academic performance will hopefully result in
more effective strategies for reducing rates of STIs and unintended
pregnancies on college campuses. The need for a greater understanding of
college students' health risk behaviors is underscored by the
potential repercussions for these individuals' personal and
academic goals.

REFERENCES

American College Health Association. (2006). American College
Health Association--National College Health Assessment (ACHA-NCHA)
Spring 2004 reference group data report (abridged). Journal of American
College Health, 54, 201-211.

Astin, A. W. (1993). What matters in college: Four critical years
revisited. San Francisco: Jossey-Bass.

Barry, A. E. (2007). Using theory-based constructs to explore the
impact of Greek membership on alcohol-related beliefs and behaviors: a
systematic literature review. Journal of American College Health, 56,
307-315.

Lewis, M. A. & Neighbors, C. (2006). Social norms approaches
using descriptive drinking education: A review of the research on
personalized normative feedback. Journal of American College Health, 54,
213-218.

Wechsler, H., Lee, J. E., Kuo, M. & Lee, H. (2000). College
binge drinking in the 1990s: a continuing problem. Results of the
Harvard School of Public Health 1999 College Alcohol Study. Journal of
American College Health, 48, 199-210

Kristen Scholly, PhD, is affiliated with the Department of
Educational Administration, College of Education, University of Hawaii
at Manoa, Honolulu, HI 96822. Alan R. Katz, MD, MPH, is affiliated with
the Department of Public Health Sciences, John A. Burns School of
Medicine, University of Hawaii at Manoa, Honolulu, HI 96822. Darnell
Cole, PhD, is affiliated with the Rossier School of Education,
University of Southern California, Los Angeles, CA 90089. Ronald H.
Heck, PhD, is affiliated with Department of Educational Administration,
College of Education, University of Hawaii at Manoa, Honolulu, HI 96822.